[5-Year-Follow-up of the MEmbeR Multicenter Study on Medical-Occupational Rehabilitation]. / 5-Jahres-Follow-Up der multizentrischen Evaluationsstudie zur medizinisch-beruflichen Rehabilitation (MEmbeR).

In Germany, medical-occupational rehabilitation represents an essential link between rehabilitation programs focusing either on medical or occupational rehabilitation. Its main objective is return to work. The current study presents the vocational integration 5 years after medical-occupational rehabilitation and determines possible prognostic factors for long-term occupational integration. To evaluate the effectiveness of medical-occupational rehabilitation, a 5-year-follow-up interview was conducted with participants (n=105) of the multicenter study on medical-occupational rehabilitation (MEmbeR). As a main result, 76% of the participants were still employed 5 years after medical-occupational rehabilitation and the return to work rate was 57%. Prognostic factors for long-term occupational integration could not be identified. However, a low degree of disability, an unrestricted capacity for teamwork as well as an unrestricted ability to judge might be beneficial factors for a successful reintegration. The high amount of participants who returned to work 5 years after medical-occupational rehabilitation, supports the concept of medical-occupational rehabilitation. However, more studies are needed to identify further factors influencing the outcome.

[Assessment of Occupational Problems in Neurological Rehabilitation]. / Assessment beruflicher Problemlagen in der Neurorehabilitation.

Introduction: The so-called Würzburg Screening (WS) is recommended for assessing occupational problems among rehabilitation patients. However, it is unclear whether it can be used in neurological rehabilitation. Data of the WS as well as of a medical opinion of occupational problems (both assessed at the beginning of rehabilitation) was compared with prognoses of occupation at the end of rehabilitation. Methods: Data of 347 neurological post-acute rehabilitation patients were analyzed. Data of the WS as well as of a medical opinion of occupational problems (both assessed at the beginning of rehabilitation) was compared with prognoses of occupation at the end of rehabilitation. Results: The sensitivity of the WS to predict poor occupational outcome was 61.5 % while its specificity was 59.4 %. When combined with medical opinion, its sensitivity was higher (75 %) with a specificity of only 50.9 %. Regarding the prediction of further need for rehabilitation, the WS had a sensitivity of 56.3 % and specificity 76.4 %. Combined with the medical assessment, the sensitivity increased to 76.5 %, whereas the specificity was slightly lower with 76,1 %. Conclusion: Neither the WS alone nor the combination with a medical assessment allows valid prognoses of occupational problems and further rehabilitation needs at the beginning of rehabilitation. This suggests that the validity of the WS, which has been demonstrated for other indications, does not simply apply to neurological rehabilitation. Further studies are necessary to determine the validity of this scale.

Nutritional situation of enterally fed patients in neurological early rehabilitation and impact of nutritional status on functional outcome.

BACKGROUND & AIMS: Studies focusing on the nutritional status of neurological and neurosurgical early rehabilitation (NNER) patients are limited. The aim of the current study was to determine the nutritional status of NNER patients upon admission, to observe weight changes and to investigate the influence of nutritional status on complications and outcome. METHODS: 109 enterally fed NNER patients were included in this prospective observational study. Weight changes, complications, neurological outcome scores (Early Rehabilitation Index [ERI], Barthel-Index [BI]) and the length of stay (LOS) were recorded. In addition, daily energy requirement was calculated and compared with daily intake to identify under-/optimally- and oversupplied patients. RESULTS: A general weight loss was observed in the study group. Weight changes during rehabilitation differed between men and women as well as between under- and oversupplied patients. Nutritional supply during rehabilitation had no influence on the LOS and the change of neurological outcome scores, but significant differences in the frequency of nosocomial infections was observed between under-/optimally- and oversupplied patients. The nutritional status (weight group on admission) had a crucial impact on neurological outcome scores, indicated by lower BI at discharge in normal-compared to underweight patients. In addition, underweight + undersupplied patients showed a significantly lower improvement of the BI than underweight + oversupplied patients. To the contrary, underweight + oversupplied patients had a higher BI improvement than underweight + optimally supplied patients. CONCLUSIONS: The nutritional status upon admission in combination with the nutritional supply during rehabilitation appears to have an impact on changes of neurological outcome scores.

Standardized nutritional supply versus individual nutritional assessment: Impact on weight changes, complications and functional outcome from neurological early rehabilitation.

BACKGROUND & AIMS: Approximately 55% of neurological and neurosurgical early rehabilitation (NNER) patients are in need of enteral nutrition, but long-term nutritional assessment of these critically ill patients is suboptimal. Therefore, this study analyzed the effect of an individual nutritional assessment on weight changes during rehabilitation and impact on complications and functional outcome. METHODS: 170 NNER patients on enteral nutrition were enrolled in the study. According to the initial ward, patients were assigned to receive standardized enteral nutrition (n = 107, control group) or an individual nutritional assessment (n = 63, intervention group). Weight changes, complications, assessment of the functional outcome (Early Rehabilitation Index, Barthel Index, Early Rehabilitation Barthel Index) and the length of stay were recorded and compared between groups using non-parametric tests for non-paired samples (Mann-Whitney U test for metric data or the χ2 test for categorical data) or paired samples (Wilcoxon test). In addition, daily energy requirement was calculated and compared with daily intake. Correlation analysis by Spearman was performed to investigate linear relationship between weight changes and the difference of administered and calculated calories in both study groups. RESULTS: A weight loss was observed in the control group, whereas the weight of the intervention group remained stable over time. The difference between calculated and administered calories correlated with weight changes in the control group. Regarding complications during rehabilitation, control patients showed more frequently impaired diuresis. In addition, control patients were suffering longer from diarrhea than patients of the intervention group. Both groups improved in functional status to a comparable degree. Relationships between these improvements and weight changes or administered calories could not be found. CONCLUSIONS: Individual nutritional assessment had not an additional affect for the improvement of functional outcome or the prevention of complications. However, weight turned out to be more stable and signs of nutritional incompatibilities are less frequent among patients being treated with an individualized nutritional assessment.

The prehospital phase of acute myocardial infarction in the era of thrombolysis.

To evaluate the factors affecting the time between symptom onset and hospital arrival in patients with acute myocardial infarction (AMI), we gave a detailed questionnaire to all who were admitted or transferred with AMI from January 1988 to February 1989. In these 126 patients (94 men, 32 women) the mean prehospital time was 5.9 +/- 11.0 hours (median 2.0, range 0.4 to 69.0). The time between symptom onset and reaching a decision that medical care should be sought was 62% of the mean prehospital time. In 100 (79%) patients, the prehospital time was less than or equal to 6 hours; of these, 61 (61%) were retrospectively judged to have been optimal candidates for lytic therapy. Stepwise multiple regression selected the following 4 variables as independent predictors of prehospital time: slow symptom progression; low income; female gender; and advanced age. All of these variables are predictive (p less than 0.03) of increased prehospital time; absence of prior AMI was of borderline additional significance (p = 0.053). Similarly, logistic regression analysis selected slow symptom progression, female gender and low income as significant (p less than or equal to 0.02) independent predictors of prehospital time greater than 6 hours. The logistic regression model incorporating these 3 variables had a sensitivity of 54%, a specificity of 95% and a positive predictive value of 72% in identifying patients with prehospital time greater than 6 hours. Thus, these data indicate it is possible to characterize patients likely to experience undue prehospital delay during AMI, which may be of importance to future public education efforts.

Atrial flutter and fibrillation following bee stings.

Atrial tachyarrhythmias following bee stings in 2 patients are described. These have not been previously reported in the absence of anaphylaxis.

Lipoprotein and apolipoprotein levels in angiographically defined coronary atherosclerosis.

Recent studies suggest that apolipoproteins and subfractions of high-density lipoprotein (HDL) cholesterol may be better predictors of atherosclerotic coronary artery disease (CAD) than are plasma cholesterol and total HDL cholesterol. To examine this hypothesis, plasma cholesterol and triglyceride, cholesterol of low-density lipoprotein, HDL and its subfractions 2 and 3, apolipoprotein A-I, the apolipoprotein B of low-density lipoprotein, the ratio of apolipoprotein EII to EIII, and ratios of several of these variables were measured in a selected series of 126 patients (83 men and 43 women) who underwent coronary angiography for suspected CAD. Mean values of many of these variables differed significantly between the men with CAD and the men without significant CAD, when controlled for age, use of beta blockers and diuretic drugs. Using multivariate logistic regression analysis, the only variable that made a significant independent contribution in predicting CAD in men was the ratio of HDL cholesterol to total plasma cholesterol (p less than 0.0001). The mean of this ratio was 0.17 +/- 0.01 mg/dl in the men with CAD and 0.23 +/- 0.02 mg/dl in the male controls. All men with ratios of less than 0.15 mg/dl had significant CAD, defined as 50% or greater luminal diameter narrowing of 1 or more of the major coronary arteries. No measurement was a significant univariate or multivariate predictor of CAD in the women, but the power to detect such predictors was reduced because of small group sizes. In conclusion, the ratio of HDL cholesterol to plasma cholesterol may be superior to many of the more recently described lipoprotein and apolipoprotein-derived predictors of CAD.

Diagnostic utility of memory equipped transtelephonic monitors.

The diagnostic utility of memory-equipped transtelephonic electrocardiographic monitors was evaluated in a series of 31 patients referred for evaluation of unexplained syncope (16), presyncope (8), or palpitations (7). Previous nondiagnostic workups included 4 +/- 1 days (mean +/- standard error of the mean) of 24-hour Holter and/or in-hospital telemetric monitoring per patient. The duration of monitoring averaged 31 +/- 2 days per patient. Electrocardiographic recordings were made during a typical symptom episode in 9 of 31 (29%) patients, including 0 of 16 with syncope, 3 of 8 (37%) with presyncope, and 6 of 7 (86%) with palpitations (p less than .001). The probability of recording typical symptoms was strongly influenced by their previous frequency. Potentially causal arrhythmias were documented in 5 of 7 (71%) patients with palpitations, but in none of the other symptom subgroups (p less than .001). Monitoring led to changes in therapy in only two patients. During followup of 9 +/- 1 months, symptoms continued in 4 of 16 (25%) with syncope, 7 of 8 (87%) with presyncope, and 7 of 7 (100%) with palpitations (p = .001). The diagnostic utility of these devices thus appears to be low in patients with previously unexplained syncope or presyncope. The yield was high in those monitored for palpitations, which may be in part attributable to the greater frequency of symptoms observed in this group.

PVCs in the elderly: when to start worrying.

Recent studies using electrophysiologic testing have established that effective antiarrhythmic therapy does indeed prolong survival in the high-risk group of survivors of out-of-hospital cardiac arrest. Ideally, the initial antiarrhythmic agent is selected on the basis of its efficacy, side effects, ease of administration, cost, and interaction with other medications. To a large extent, however, selection remains empiric. In patients without QT prolongation, long-acting procainamide or quinidine are usually tried first.

Mitral valve prolapse. Practical aspects of diagnosis and management.

Because auscultatory findings may vary greatly among patients with suspected mitral valve prolapse, careful examination is essential to avoid diagnostic misinterpretation. The presence of mitral valve prolapse can be confirmed by echocardiography. Clinicians should be reluctant to attribute symptoms to the echo or physical finding of prolapse. Prognosis in the vast majority of patients is excellent, and reassurance is a critical element of successful patient management. Endocarditis prophylaxis and periodic follow-up examinations are appropriate for patients with mitral regurgitation.

What are the facts on cholesterol? Questions physicians often ask about screening and treatment.

In spite of, or possibly because of, the many studies about cholesterol in the literature, some physicians remain confused or skeptical about the issues and conclusions. Reasonably clear evidence indicates that lowering the total serum cholesterol level can lessen the likelihood of primary coronary artery disease. There is no reason to believe that this benefit would not be conferred on women and the elderly, even though specific studies have not been done in these populations. Also, lowered cholesterol levels have been shown to correlate with regression of established atherosclerotic lesions. Moderate dietary changes can have significant impact on serum lipid levels in many patients, and a trial of low-dose drug therapy can usually identify those who may benefit from combination therapy.

Mitral valve prolapse syndrome revisited.

Mitral valve prolapse is a relatively common cardiac finding which, unfortunately, is often overdiagnosed and overtreated. For most patients, it can be regarded as an incidental observation without significance in terms of symptoms or prognosis. This article reviews our current understanding of what has been aptly called "the mitral prolapse fiasco".

Survey of physician practices in managing patients with chronic ventricular arrhythmias.

To better understand how physicians manage patients with chronic ventricular arrhythmias, questionnaires were mailed in July, 1989, to 680 internists, family physicians and cardiologists in West Virginia. Responses were returned by 35 per cent; those from 33 physicians who seldom prescribed drugs to treat arrhythmias were excluded from analysis. Quinidine and procainamide were the preferred first-line antiarrhythmics for 53.3 per cent and 24.3 per cent of physicians, respectively. Control of symptoms was listed as the usual indication for therapy by 32.2 per cent, and improvement in prognosis by 20.1 per cent. Physicians perceived a high prognostic benefit to antiarrhythmic treatment in patients with sustained ventricular tachycardia or history of cardiac arrest, and a generally low prognostic benefit in those with mitral valve prolapse. Opinion was divided on the prognostic benefit in other patient groups including those with frequent ventricular premature beats following myocardial infarction. These results help quantify current physician practices in managing patients with chronic ventricular arrhythmias.

Radiofrequency catheter ablation of cardiac arrhythmias: initial WVU experience.

Radiofrequency catheter ablation is a method of selectively destroying cardiac tissue to treat various arrhythmias. In a relatively short time, it has evolved from an investigational tool to a widely applied clinical technique (1). This article reviews the current status of radiofrequency catheter ablation and reports on the results of its initial clinical use in 14 patients at West Virginia University Hospital.

Wolff-Parkinson-White syndrome.

This article discusses a patient with Wolff-Parkinson-White syndrome who recently underwent surgical ablation of her accessory pathway at West Virginia University Health Sciences Center. Surgical cure of this arrhythmia is possible in a high percentage of cases and should be strongly considered for those with life-threatening arrhythmias or poorly controlled symptoms.

Update on therapy for atrial fibrillation.

This article reviews newer trends in the management of patients with atrial fibrillation. The roles of chronic antiarrhythmic therapy, anticoagulation, and nonpharmacologic treatments are discussed.

Radiofrequency catheter ablation in pediatric patients with supraventricular arrhythmias.

Radiofrequency (RF) ablation of foci leading to abnormal cardiac rhythms is rapidly becoming the procedure of choice in the management of arrhythmias in adults. This report reviews our initial experience with RF ablation in the pediatric population.

The use of radiofrequency catheter ablation to cure dilated cardiomyopathy.

Incessant supraventricular tachycardia can cause a dilated cardiomyopathy. This article discusses the case of a 55-year-old woman whose cardiomyopathy was reversed when she underwent successful radiofrequency catheter ablation of a unifocal atrial tachycardia.